We conducted an epidemiologic survey to determine the seroprevalence of SARS-CoV-2 anti-nucleocapsid (anti-N) and anti-spike (anti-S) protein IgG from 1 March to 11 April 2022 after the BA.1-dominant wave had subsided in South Africa and prior to another wave dominated by the BA.4 and BA.5 (BA.4/BA.5) sub-lineages. We also analysed epidemiologic trends in Gauteng Province for cases, hospitalizations, recorded deaths, and excess deaths were evaluated from the inception of the pandemic through 17 November 2022. Despite only 26.7% (1995/7470) of individuals having received a COVID-19 vaccine, the overall seropositivity for SARS-CoV-2 was 90.9% (95% confidence interval (CI), 90.2 to 91.5) at the end of the BA.1 wave, and 64% (95% CI, 61.8 to 65.9) of individuals were infected during the BA.1-dominant wave. The SARS-CoV-2 infection fatality risk was 16.5–22.3 times lower in the BA.1-dominant wave compared with the pre-BA.1 waves for recorded deaths (0.02% vs. 0.33%) and estimated excess mortality (0.03% vs. 0.67%). Although there are ongoing cases of COVID-19 infections, hospitalization and death, there has not been any meaningful resurgence of COVID-19 since the BA.1-dominant wave despite only 37.8% coverage by at least a single dose of COVID-19 vaccine in Gauteng, South Africa.

ABSTRACTBackgroundWe conducted a seroepidemiological survey from October 22 to December 9, 2021, in Gauteng Province, South Africa, to determine SARS-CoV-2 immunoglobulin G (IgG) seroprevalence primarily before the fourth wave of coronavirus disease 2019 (Covid-19), in which the B.1.1.529 (Omicron) variant was dominant. We evaluated epidemiological trends in case rates and rates of severe disease through to January 12, 2022, in Gauteng.MethodsWe contacted households from a previous seroepidemiological survey conducted from November 2020 to January 2021, plus an additional 10% of households using the same sampling framework. Dry blood spot samples were tested for anti-spike and anti-nucleocapsid protein IgG using quantitative assays on the Luminex platform. Daily case, hospital admission, and reported death data, and weekly excess deaths, were plotted over time.ResultsSamples were obtained from 7010 individuals, of whom 1319 (18.8%) had received a Covid-19 vaccine. Overall seroprevalence ranged from 56.2% (95% confidence interval [CI], 52.6 to 59.7) in children aged <12 years to 79.7% (95% CI, 77.6 to 81.5) in individuals aged >50 years. Seropositivity was more likely in vaccinated (93.1%) vs unvaccinated (68.4%) individuals. Epidemiological data showed SARS-CoV-2 infection rates increased and subsequently declined more rapidly than in previous waves. Infection rates were decoupled from Covid-19 hospitalizations, recorded deaths, and excess deaths relative to the previous three waves.ConclusionsWidespread underlying SARS-CoV-2 seropositivity was observed in Gauteng Province before the Omicron-dominant wave. Epidemiological data showed a decoupling of hospitalization and death rates from infection rate during Omicron circulation.

Background: The B.1.1.529 (Omicron BA.1) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in mid-November 2021 in Southern Africa and subsequently resulted in a global resurgence of coronavirus disease 2019 (Covid-19). One-year later, sub-lineages of Omicron dominate globally as the cause of Covid-19. We undertook a population-based sero-survey to investigate the force of SARS-CoV-2 infections during the BA.1 dominant wave and its contribution to ongoing evolution of infection-induced immunity, and the subsequent trajectory of severe and fatal Covid-19 in Gauteng (South Africa). Methods: We conducted an epidemiologic survey to determine the sero-prevalence of SARS-CoV-2 anti-nucleocapsid (anti-N) and anti-spike (anti-S) protein IgG from March 1 to April 11, 2022, after the BA.1-dominant wave had subsided, and prior to another wave dominated by the BA.4 and BA.5 (BA.4/BA.5) sub-lineages. Population-based sampling included households in an earlier survey from October 22 to December 9, 2021 preceding the BA.1 dominant wave. Dried-blood-spot samples were quantitatively tested for anti-N and anti-S IgG. Epidemiologic trends in Gauteng for cases, hospitalizations, recorded deaths, and excess deaths were evaluated from the inception of the pandemic to the onset of the BA.1 dominant wave (pre-BA.1), during the BA.1 dominant wave (October 23, 2021 to March 21, 2022), and the subsequent eight-month period until November 17, 2022 when multiple sub-lineages of Omicron circulated. Results: The 7510 participants included 2420 with paired samples from the earlier survey. Despite only 26.7% (1995/7470) of individuals having received a Covid-19 vaccine, the overall sero-prevalence of either anti-N or anti-S IgG at the end of the BA.1 wave was 90.9% (95% confidence interval [CI], 90.2 to 91.5), including 89.5% in Covid-19 unvaccinated individuals. The rate of infection during the BA.1 dominant wave was 64% (95%CI, 61.8 to 65.9), in individuals with paired samples. Of all cumulative recorded Covid-19 hospitalisations and deaths, 13.8% and 5.8% occurred during the BA.1-dominant wave over a five-month period, whilst the subsequent eight-month Omicron sub-lineage era contributed a further 7.2% and 3.0%, respectively. The SARS-CoV-2 infection fatality risk 16.5-22.3 times lower in the BA.1-dominant compared with pre-BA.1 waves for recorded deaths (0.02% vs. 0.33%, a factor of 16.5) and estimated excess mortality (0.03% vs. 0.67%, a factor of 22.3). Conclusions: South Africa experienced a higher rate of serological inferred infections in the BA.1-dominant wave, resulting in an increase in infection-induced immunity from 73% (pre-BA.1) to 90% (post-BA.1 wave). Although there are ongoing cases of Covid-19 infections, hospitalization and death, there has not been any meaningful resurgence of Covid-19 since the BA.1- dominant wave despite only modest (37.8%) coverage by at least a single dose of Covid-19 vaccine in Gauteng. Funding Information: Funded by the Bill and Melinda Gates Foundation. Declaration of Interests: Dr. Madhi reports grants from the Bill & Melinda Gates Foundation during the conduct of the study, grants and personal fees from the Bill & Melinda Gates Foundation, grants from the South African Medical Research Council, grants from Novavax, grants from Pfizer, grants from Minervax, and grants from the European & Developing Countries Clinical Trials Partnership, outside the submitted work. Dr. Kwatra, Dr. Dhar, Mr. Mukendi, Dr Alane Izu and Dr. Mutevedzi report grants from the Bill & Melinda Gates Foundation during the conduct of the study. Mr. Welch shareholdings in Adcock Ingram Holdings Ltd, Aspen Pharmacare Holdings Ltd, Dischem Pharmacies Ltd, Discovery Ltd, and Netcare Ltd, outside the submitted work. Dr. Myers, Dr. Jassat, and Dr. Blumberg have nothing to disclose. Ethics Considerations: The Human Research Ethics Committee at the University of the Witwatersrand granted a waiver for ethics approval of the survey, which was being done as part of public health surveillance by the Gauteng Department of Health. All participants were, however, required to provide written informed consent; and individuals within a household were free to decline participation.

ABSTRACTBackgroundThe B.1.1.529 (Omicron BA.1) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused a global resurgence of coronavirus disease 2019 (Covid-19). The contribution of BA.1 infection to population immunity and its effect on subsequent resurgence of B.1.1.529 sub-lineages warrant investigation.MethodsWe conducted an epidemiologic survey to determine the sero-prevalence of SARS-CoV-2 IgG from March 1 to April 11, 2022, after the BA.1-dominant wave had subsided in Gauteng (South Africa), and prior to a resurgence of Covid-19 dominated by the BA.4 and BA.5 (BA.4/BA.5) sub-lineages. Population-based sampling included households in an earlier survey from October 22 to December 9, 2021 preceding the BA.1 dominant wave. Dried-blood-spot samples were quantitatively tested for IgG against SARS-CoV-2 spike protein and nucleocapsid protein. Epidemiologic trends in Gauteng for cases, hospitalizations, recorded deaths, and excess deaths were evaluated from the inception of the pandemic to the onset of the BA.1 dominant wave (pre-BA.1), during the BA.1 dominant wave, and for the BA.4/BA.5 dominant wave through June 6, 2022.ResultsThe 7510 participants included 2420 with paired samples from the earlier survey. Despite only 26.7% (1995/7470) of individuals having received a Covid-19 vaccine, the overall sero-prevalence was 90.9% (95% confidence interval [CI], 90.2 to 91.5), including 89.5% in Covid-19 unvaccinated individuals. Sixty-four percent (95%CI, 61.8-65.9) of individuals with paired samples had serological evidence of SARS-CoV-2 infection during the BA.1 dominant wave. Of all cumulative recorded hospitalisations and deaths, 14.1% and 5.9% were contributed by the BA.1 dominant wave, and 5.1% and 1.6% by the BA.4/BA.5 dominant wave. The SARS-CoV-2 infection fatality risk was lower in the BA.1 compared with pre-BA.1 waves for recorded deaths (0.02% vs. 0.33%) and Covid-19 attributable deaths based on excess mortality estimates (0.03% vs. 0.67%).ConclusionsGauteng province experienced high levels of infections in the BA.1 -dominant wave against a backdrop of high (73%) sero-prevalence. Covid-19 hospitalizations and deaths were further decoupled from infections during BA.4/BA.5 dominant wave than that observed during the BA.1 dominant wave.(Funded by the Bill and Melinda Gates Foundation.)

The Qhubeka Trust was established in 2016 in a legal settlement on behalf of former gold miners seeking compensation for silicosis contracted on the South African mines. Settlements resulting from lawsuits on behalf of gold miners aim to provide fair compensation. However, occupational exposure and medical records kept by South African mining companies for their employees have been very limited. Some claimants to the Qhubeka Trust died before medical evaluation was possible, thus potentially disadvantaging their dependants from receiving any compensation. With medical evaluation no longer possible, a statistical approach to this problem was developed. The records for claimants with medical evaluation were used to develop a logistic regression prediction model for the likelihood of silicosis, based on the potential predictors: cumulative exposure to respirable dust, age, years since first exposure, years of life lost prematurely, vital status at 31 December 2019, and a history of tuberculosis diagnosis. The prediction model allowed estimation of the likelihood of silicosis for each miner who had died without medical evaluation and is a novel approach in this setting. In addition, we were able to quantitatively evaluate the trade-offs of different silicosis risk classification thresholds in terms of true and false positives and negatives. Significance: A statistical approach can be used for risk estimation in settings where the outcome of interest is unknown for some members of a class. The likelihood of silicosis in deceased miners without medical evaluation in the Qhubeka Trust can be accurately estimated, using information from finalised claims. Strategies for classifying the silicosis status of deceased miners without medical evaluation in the Qhubeka Trust can be assessed in a rigorous, quantitative framework.

South Africa suffers from a considerable health burden including communicable disease, violence and injury as well as non-communicable diseases. Its formal health system is significantly challenged. Reducing morbidity and mortality for all South Africans requires an approach that transcends health services, where public policy addresses the broader social determinants of health by designing and implementing interventions that improve people's health more effectively than individual interventions within the health sector. Legislative, regulatory and fiscal policies could substantially and cost-effectively reduce the burden of nutrition-related non-communicable diseases. South Africa has successfully reduced the salt content of foods and there is evidence demonstrating that a 20 per cent tax on sugary beverages will reduce obesity. Facilitators and barriers for such interventions have been covered in a separate article. Some challenges are particularly difficult to overcome. This article focuses on the deep historical roots of the South African sugar industry and its influence on dietary sugar consumption at the population level. The sugar industry is a prime example of a colonial activity shaping the economy, polity, penetration of sugar content into food products, and diets over an extended historical period. In the modern, and specifically the post-apartheid, period the sugar industry has proved resilient. The priority for black empowerment in policy matters since the end of apartheid, and recent economic policy, have facilitated the promotion of products regardless of their known economic, social and health harms. These pressures have led contradictorily to the retention of a large privileged sector in the South African sugar industry, while simultaneously enriching a few select black entrepreneurs on the one hand, and impoverishing the greater number of small and informal producers on the other. Similar developments have characterised the South African experience with other harmful product industries - notably alcohol and tobacco. It is argued that understanding the historical roots and dynamics of the SA sugar industry illuminates the setting of a research agenda on policy processes involving the role of corporates producing harmful products.

To the Editor: On 11 November 2015, the National Department of Health (NDoH) published the National Public Health Institute of South Africa (NAPHISA) Draft Bill 2015 for public comment. The aim of the Draft Bill is: '[t]o provide for the establishment of the National Public Health Institute of South Africa in order to conduct disease and injury surveillance and to provide specialised public health services, public health interventions, training and research directed towards the major health challenges affecting the population of the Republic.'

OBJECTIVE:To evaluate the construct of triage acuity as measured by the South African Triage Scale (SATS) against a set of reference vignettes.METHODS:A modified Delphi method was used to develop a set of reference vignettes. Delphi participants completed a 2-round consensus-building process, and independently assigned triage acuity ratings to 100 written vignettes unaware of the ratings given by others. Triage acuity ratings were summarised for all vignettes, and only those that reached 80% consensus during round 2 were included in the reference set. Triage ratings for the reference vignettes given by two independent experts using the SATS were compared with the ratings given by the international Delphi panel. Measures of sensitivity, specificity, associated percentages for over-triage/under-triage were used to evaluate the construct of triage acuity (as measured by the SATS) by examining the association between the ratings by the two experts and the international panel.RESULTS:On completion of the Delphi process, 42 of the 100 vignettes reached 80% consensus on their acuity rating and made up the reference set. On average, over all acuity levels, sensitivity was 74% (CI 64% to 82%), specificity 92% (CI 87% to 94%), under-triage occurred 14% (CI 8% to 23%) and over-triage 12% (CI 8% to 23%) of the time.CONCLUSIONS:The results of this study provide an alternative to evaluating triage scales against the construct of acuity as measured with the SATS. This method of using 80% consensus vignettes may, however, systematically bias the validity estimate towards better performance.

Objective. We assessed the effectiveness of South Africa’s Firearm Control Act (FCA), passed in 2000, on firearm homicide rates compared with rates of nonfirearm homicide across 5 South African cities from 2001 to 2005. Methods. We conducted a retrospective population-based study of 37 067 firearm and nonfirearm homicide cases. Generalized linear models helped estimate and compare time trends of firearm and nonfirearm homicides, adjusting for age, sex, race, day of week, city, year of death, and population size. Results. There was a statistically significant decreasing trend regarding firearm homicides from 2001, with an adjusted year-on-year homicide rate ratio of 0.864 (95% confidence interval [CI] = 0.848, 0.880), representing a decrease of 13.6% per annum. The year-on-year decrease in nonfirearm homicide rates was also significant, but considerably lower at 0.976 (95% CI = 0.954, 0.997). Results suggest that 4585 (95% CI = 4427, 4723) lives were saved across 5 cities from 2001 to 2005 because of the FCA. Conclusions. Strength, timing and consistent decline suggest stricter gun control mediated by the FCA accounted for a significant decrease in homicide overall, and firearm homicide in particular, during the study period.

In August 2013, the Western Cape Government adopted an Integrated Provincial Violence Prevention Policy Framework initiated by the provincial Department of Health in response to the unusually high incidence of, and health burden arising from, interpersonal violence. The policy framework encompasses a more comprehensive intersectoral approach to the prevention of violence than the traditional criminal justice and security-centred approach typically promoted in South Africa as the conventional wisdom. It aims to bring coherence and clarity to the government's objectives in the field of violence prevention by way of a whole-of-government approach encompassing all sectors. The Policy Framework attempts to balance short-term evidence-based interventions, such as reducing the availability and harmful use of alcohol, with longer term interventions that require the state and all citizens to take active responsibility in addressing more holistically the complex social norms that support violence. It is consonant with a “whole-of-society” approach current in the South African polity to policy formulation and implementation, and is underpinned by the public health-centred guidelines set out by the international Global Campaign for the Prevention of Violence. The policy framework supports evidence-based approaches for violence prevention and a review and consultation process aimed at aligning existing performance priorities and deliverables across departments. One year after its adoption we review the uptake of this policy and reflect on some of its early successes as well as barriers to its implementation. We identify early resistance arising from its conflict with intra-departmental priorities, the impact of competing policies and directives, and we propose a research agenda to support its uptake.

In addition to the ethical practice of individual health professionals, bioethical debate about conflict of interest (CoI) must include the institutional ethics of public policy-making, as failure to establish independence from powerful stakeholder influence may pervert public health goals. All involved in public policy processes are accountable for CoI, including experts, scientists, professionals, industry and government officials. The liquor industry in South Africa is presented as a case study. Generic principles of how to identify, manage and address CoI are discussed. We propose that health professionals and policy makers should avoid partnering with industries that are harmful to health. Regarding institutional CoI, we recommend that there should be effective policies, procedures and processes for governing public-private joint ventures with such industries. These include arms-length funding, maintaining the balance between contesting vested interests, and full disclosure of the identity and affiliations of all participants in structures and reports pertaining to public policy-making.

Objective: To estimate the inter-rater reliability of triage ratings within individual cadres of health care workers (HCWs) and between different cadres of HCWs using the South African Triage Scale (SATS).Methods: Five final year medical students (FMSs), two enrolled nurses (ENs) and two Enrolled Nursing Assistants (ENAs), who had all been trained in the use of the SATS, were selected to prospectively triage Emergency Centre (EC) patients in real time. Twenty five patients were triaged twice on the first day by individual participants, and another 25 were triaged twice by a collaborative team on the second day. Quadratically weighted kappa (QWK) point estimates were calculated with 95% confidence intervals to assess agreement.Results: For 25 patients analysed on day one, the QWK values were very high within professions triaging individually: among the FMSs (QWK = 0.94; 95% CI: 0.82-1.0), among the ENs (QWK = 0.92; 95% CI: 0.74-1.0) and moderate between the FMSs and ENs (QWK = 0.57; 95% CI: 0.33-0.81). For 25 patients analysed on day two a team of ENA and FMS, triaging collaboratively, demonstrated moderate agreement (QWK = 0.65; 95% CI: 0.46-0.85).Conclusion: The inter-rater reliability of SATS ratings is excellent within individual HCWs, but significantly lower between different HCWs. This confirms previous reliability studies of the SATS using vignettes and if validated by larger studies would support the feasibility of further implementation of the SATS in primary health care settings across the Western Cape. (C) 2011 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved.

OBJECTIVE:To estimate the inter- and intra-rater reliability of triage ratings on Emergency Centre patients by South African nurses and doctors using the South African Triage Scale (SATS). METHODS:A cross-sectional reliability study was performed. Five emergency physicians and ten enrolled nursing assistants independently assigned triage categories to 100 written vignettes unaware of the ratings given by others. Four different quantitative reliability measures were calculated and compared. Graphical displays portrayed rating distributions for vignettes with mean ratings at different acuity categories. RESULTS:The estimated quadratically weighted kappa for the group of emergency physicians was 0.76 (95% CI: 0.67-0.84) and for the group of nurses 0.66 (95% CI: 0.58-0.74). These values were close to the estimated intra-class correlation coefficients. For intra-rater reliability, the average exact agreement was 84%. The graphical displays showed that the least variability was evident in the vignettes that had a mean rating of 'emergency', 'very urgent' or 'routine'. CONCLUSION:This study indicates good inter- and intra-rater reliability among nurses and doctors using the SATS. It suggests that the SATS is reliably applied, and supports the feasibility of further implementation of the SATS in similar settings.

To the Editor: van der Wulp et al. [[1]van der Wulp I. van Stel F. Adjusted weighted kappa for severity of mistriage decreases reported reliability of emergency department triage systems: a comparative study.J Clin Epidemiol. 2009; 62: 1196-1201Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] make a compelling argument regarding the assessment of emergency department triage systems. We agree that neither the linear nor quadratically weighted kappa statistics adequately takes into account the severity of mistriage in ordinal triage scales (despite the fact that these appear to be the most commonly quoted statistics) and that an elaborated weighting scheme is long overdue. Although we congratulate the authors on the first step in this direction, we believe that when triage scales stipulate different care pathways for different triage categories, algorithms for determining over- or undertriage should be constructed so as to account for these differences. It is not clear whether this is the case with this new algorithm. For instance, a patient undertriaged using the Australasian triage scale (ATS) will have a different path through the emergency care system to one undertriaged using the Manchester triage system (MTS). If a patient was triaged ATS-3 instead of ATS-2, she would be seen in 30 minutes rather than 10 minutes—if she was triaged MTS yellow (third) instead of orange (second), she will be seen in 60 minutes rather than 10 minutes. Undertriage would be more severe using the MTS. This difference needs to be accounted for in some way—either quantitatively, semi-quantitatively, or qualitatively. The effect of overtriage is also different in different settings. For instance, the consequences of overtriage would be more severe in systems with fewer resources and increased overcrowding (e.g., South Africa as opposed to Canada). From a qualitative perspective, setting is critical. A new tool, therefore, should ideally account for both qualitative factors, such as setting, and quantitative factors, such as different weightings among levels of mistriage. As with the ideal triage system, such an analytical tool may not be completely realizable, but we echo the authors' call for further research in this direction.

Objective: To examine whether current validation methods of emergency department triage scales actually assess the instrument's validity.Methods: Optimal methods of emergency department triage scale validation are examined in developed countries and their application to developing countries is considered.Results and conclusion: Numerous limitations are embedded in the process of validating triage scales. Methods of triage scale validation in developed countries may not be appropriate and repeatable in developing countries. Even in developed countries there are problems in conceptualising validation methods. A new consensus building validation approach has been constructed and recommended for a developing country setting. The Delphi method, a consensual validation process, is advanced as a more appropriate alternative for validating triage scales in developing countries.

Abstract Background The utility of blood reproductive endocrine biomarkers for assessing or estimating semen quality was explored. Methods A cross-sectional study of 47 DDT exposed malaria vector control workers was performed. Tests included blood basal and post gonadotrophin releasing hormone (GnRH), lutenizing hormone (LH), follicle stimulating hormone (FSH), testosterone, sex hormone binding globulin (SHBG), estradiol (E2) and inhibin; a questionnaire (demographics and general medical history); a physical examination and semen analysis. Semen parameters were determined using either/or or both WHO or the strict Tygerberg criteria. Relationships between semen parameters and endocrine measures were adjusted for age, duration of abstinence before sampling, presence of physical abnormalities and fever in the last two months. All relationships between specific endocrine hormones were adjusted for age and basal SHBG. Results Multiple logistic regression showed a consistent positive relationship (prevalence odds ratio (POR) = 8.2, CI:1.4–49.2) between low basal inhibin (<100 pg/ml) and low semen count (< 40 million) and density (< 20 million/ml); consistent positive, but weaker relationships (1> POR < 2) between abnormally low semen count as well as density and baseline and post GnRH FSH; and positive relationships (POR = 37, CI:2–655) between the prevalence of high basal estradiol (> 50 pg/ml) and abnormal morphology (proportion < 5%) and low motility (proportion <50%). Most of the expected physiological relationships between specific endocrines were significant. Conclusion The study has demonstrated that low basal inhibin, elevated basal FSH and high basal E2 can serve as markers of impaired semen quality.

The Finnish Institute of Occupational Health (FIOH) has received support from the World Health Organization (WHO) and the International Labor Office (ILO) to publish the African Newsletter on Occupational Health and Safety. The African Newsletter on Occupational Health and Safety should not be a medium for industry propaganda, or the source of misinformation among the workers of Africa. Instead, FIOH should provide the same level of scientific information in Africa that it does in Finland and other developed countries.

Since 1996, the University of Michigan's Fogarty International Center training and research program in Environmental and Occupational Health (EOH) in Southern Africa has contributed to capacity development in the 14 countries of the Southern African Development Community. Methods include training citizens from the region in master's, doctoral, and short-term focused programs; assisting the development of graduate programs in EOH at institutions, developing resources for distance-based degree programs; direct support ofjunior and mid-level researchers, and organizing regional short courses and regional conferences. Substantial EOH resources now present in South Africa are leveraged to assist capacity development in the rest of the region. The program's successes appear to be due to strong regional leadership and oversight structures, a strategy of developing EOH resource centers in several countries, and close collaboration with other regional and international EOH programs.